Concomitant Use of Glycoprotein IIb/IIIa Inhibitor and Streptokinase after Unsuccessful Rescue Angioplasty

José Marconi Almeida de Sousa, Leonardo Severino, Ederlon de Carvalho Rezende, Jairon Nascimento Alencar, Valter Correia de Lima, João Lourenço V. Hermann
2002 Arquivos Brasileiros de Cardiologia  
A 38-year-old man with acute myocardial infarction in the lower wall affecting the right ventricle underwent thrombolytic treatment with streptokinase. Approximately 2 hours after the thrombolytic treatment started, he presented with signs of coronary reocclusion. He underwent emergency cineangiocoronariography that revealed that his right coronary artery was completely occluded by a clot. He unsuccessfully underwent angioplasty and stent implantation. After the concomitant use of glycoprotein
more » ... se of glycoprotein IIb/IIIa inhibitor, coronary TIMI III flow was achieved without additional dilations, and he was discharged from the hospital 5 days later with no further complications. Antiplatelet therapy for acute coronary syndrome is widely established 1 . As for acute myocardial infarction, the data from the ISIS 2 study showed clearly that acetylsalicylic acid, alone and/or combined with thrombolytic therapy with streptokinase, plays a role in the reduction of mortality 2 . Over the last few years, important progress has been made in this field as new and stronger antiplatelet drugs, such as the glycoprotein IIb/IIIa inhibitors, have been discovered. However, the role of these new medications as a primary support therapy in acute myocardial infarction still needs to be better understood. Case Report A 38-year-old male patient, smoker, previously in good health, came to the emergency department complaining of a 4-hour-long oppressive retrosternal pain that had started during intense exercise, irradiating to the left upper limb, accompanied by dyspnea, sweating and vomiting, which improved slightly after sublingual nitrate and aspirin administration. On admission, he was tachypneic, with a blood pressure of 130x80mmHg and a heart rate of 80 bpm, normal pulmonary auscultation, and a regular heart pace of three beats at the 4 th sound, without murmurs. Pulses were symmetrical, and no jugular stasis was present. The electrocardiogram showed an AV dissociation, an overunlevelling of 8mm of the ST portion at D 2 , D 3 , and the VF and of 4 mm at V 2 to V 6 , V 3 R, V 4 R, V 7 , and V 8 , and an underunlevelling at D 1 , VL, and VR ( fig. 1 ). An acute myocardial infarction was diagnosed, and 20 minutes later thrombolysis with 1,500,000 U of endovenous streptokinase was administered for 40 minutes. The patient reported moderate pain relief and had a slight reduction in the overunlevelling of the ST portion, while the AV dissociation persisted. Approximately 2 hours later, he developed recurrent pain, without any change in the initial electrocardiographic alterations. After the introduction of low-dose endovenous nitroglycerin, he experienced a slight improvement, but about an hour later, he again felt intense pain, which persisted even with nitroglycerin use, so an emergency heart catheterization was performed. Prior to this test, with persistent pain, the patient developed significant hypotension accompanied by jugular stasis and slight stertors at the lung bases, requiring dobutamine, even after adequate volemic repositioning. The procedure was started approximately 10 hours after the infarction began to develop. The left coronariography showed no atherosclerotic lesions. The right coronariography showed a dominant, gross-caliber right coronary artery to be totally occluded at its proximal third ( fig. 2) . A guiding lead was threaded to the distal third of the right coronary artery without any difficulty. Then, insufflation with a 3.5x20mm balloon was performed for 2 minutes. The control coronariography ( fig. 3) showed a TIMI II flow and a type B dissection at the balloon insufflation site. It was then decided to implant a 4.0x15mm NIR stent, which was done with no difficulty. Afterwards, a control coronariography was performed that showed the right coronary artery to be totally occluded where the stent had been placed ( fig. 4) . The patient was still hypotensive, slightly dyspneic, tachy-
doi:10.1590/s0066-782x2002000400009 pmid:12011958 fatcat:slwppdavlba5znxueoucxwozlu